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Sex segregation and sport
  1. Arne Ljungqvist
  1. Correspondence to Dr Arne Ljungqvist, Anti-Doping Foundation, Stockholm, Sweden; arne.ljungqvist{at}

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After the second world war, success in elite sport slowly became increasingly important for both the individual athlete and his/her country. Since success in most sports depends on physical strength, men usually outperform women to a significant degree due to their higher levels of the male sex hormone testosterone which is a powerful androgenic-anabolic substance. Consequently, it also became increasingly important to protect female competitions from male imposters. Procedures for this purpose were introduced as from the 1960s and named ‘Gender verification’. As science developed, however, the procedures were found to be either unscientific or unethical, or both. After a lengthy struggle, the International Association of Athletics Federations (IAAF) was the first international sports organisation to abandon so-called gender verification in 1991.1 Eight years later, the IOC did the same, and the remaining international sports federations followed suit. At that time, the issue of participation of transgender athletes was not specifically addressed in sport.

In 2003, a National Olympic Committee asked the IOC Medical department for guidance concerning a female athlete. She had transitioned from the male sex and her female fellow competitors questioned her participation. In the absence of any rules or guidelines, the IOC Medical Commission convened a group of experts to a consensus meeting in Stockholm in October 2003. It arrived at a number of requirements that it was recommended transgender athletes be required to fulfil in order to be eligible to compete in the category consistent with their gender identity. The recommendations were approved by the IOC Executive Board in March 2004 and became known as ‘The Stockholm Recommendations’.2 They were subsequently amended at a further consensus meeting in 2015.3

At the Stockholm meeting, the matter of intersex athletes’ participation in sport was only briefly touched on. However, the issue came back strongly with the case of Caster Semenya at the IAAF World Championships in 2009 and the discussion that followed. It was obvious that the participation in female competition of intersex athletes with high levels of testosterone (female hyperandrogenism) needed to be addressed by sport authorities. The IOC and the IAAF therefore jointly convened 25 experts, mostly top biomedical scientists from all over the world, to a meeting in Miami in January 2010. They reached several conclusions, one being that ‘rules need to be put in place that regulate the participation of athletes with hyperandrogenism in competitions for women’.4

In October 2010, the IOC organised a further conference to consider the principles of the rule that was recommended in Miami. Again, a large expert group was present, which also included athletes and experts in sports administration, law (particularly sport and law) and human rights. The conference supported the Miami conclusions and stated that ‘the rules should have as their aim to respect the essence of the male/female classification and also guarantee the fairness and integrity of female competition for all female athletes’.4

On 5 April 2011, the IOC Executive Board confirmed ‘the need to set up clear rules to determine the eligibility of female athletes with hyperandrogenism in female competitions’.4 They also recommended that other sports organisations introduce a similar rule, adjusted for the specific sport. The medical and juridical units of the IOC then worked out the rule that came into operation for the Games in London 2012 and Sochi 2014. The IAAF took the same action a little earlier and introduced their rule in time for their World Championships in Daegu 2011, requiring such athletes to reduce their serum testosterone level below 10 nmol/L.5

In 2015, the female sprinter from India, Dutee Chand, brought her case to Court of Arbitration for Sport (CAS) against the IAAF rule arguing (among other things) that there was no scientific support for the performance-enhancing effect of high levels of endogenous testosterone. CAS disagreed but suspended the rule for 2 years pending provision of further evidence that the degree of performance advantage that hyperandrogenic females who are sensitive to testosterone enjoy over athletes with normal testosterone levels is significant enough to justify the IAAF rule. The IAAF is now coming back with further evidence.

The case is ongoing. However, should CAS not find the bulk of data now available as sufficient, and thereby declare the rule void, the matter will in no way be closed. Both the IOC Executive Board and the IAAF Council have found that a rule on female hyperandrogenism is necessary. This is particularly true at a time when rapid developments in science and society are leading to an increasing number of countries liberalising their regulations on assignment (and reassignment) of legal sex, and (in particular) recognising a third sex. Sport will have to meet those challenges by putting in place adequate rules in order to protect the integrity and fairness of sport competitions for women.



  • Handling editor Karim M Khan

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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